Fall 2017  Saber Tails 33    

Petit Basset Griffon Vendéen Club of America

PBGVCA Clinical Health Information Form

When your dog is notfeeling well, your veterinarian will oftenrun variousteststo diagnose the

problem.What we are lookingfor istheresults orfinal clinical diagnoseswhen a condition was

first confirmed.This can include major health problems such as epilepsy, vestibular disease,

congestive heartfailures, various cancers, Cushing's, Addison's, chronic irritable bowel

syndrome, pancreatitis, leukemia, tumors, patella luxation (dislocatedknee cap), POAG, lens

luxation, vaginal abnormality, stones, etc.With your veterinarian's help, please completethis

form and include any relevant information provided by your veterinarian. Ifyou have morethan

one

NEW

diagnosed conditionfor same dog, please print anotherformforeach and include 

callname in Dog Infosection. Forthe initialform, please includeas much dog information as 

is known.

DOG INFO

RegistrationName (if known):
Registration or Litter No.(ifknown):
Sire (father): 
Dam (mother):
Callname:

*

Owner's Name(s) & Address:

*

Breeder's Name(s) & Address:

Sex: 

*

Has the dog been altered?

*

Intact 

Spayed 

Neutered 

If altered, what date?
Date of Birth (if you do notknowfull date, justchose yearandarandommonth/day):

CLINICAL HEALTH INFORMATION

Entersingle diagnosed condition. If you havemorethanone NEWdiagnosed conditionfor

same dog, please print anotherformfor each and include call name in Dog Info section. For 

theinitial form, please include asmuchknown dog information.

Enter Veterinarian Information:

*

Vet Name:

Name/Location of Vet Hospital:

Enter date offinal diagnosis:

*

Enter age when diagnosed: 

*

Have you submitted your dog's DNA to the OFA/CHIC DNA Repository? 

*

 

(The CHIC DNA Repository, co-

sponsored by the Orthopedic Foundation for Animals (OFA) and the AKC Canine Health Foundation (AKC CHF), collects 

and stores canine DNA samples along with corresponding pedigree and health history information to facilitate future research 

and testing aimed at reducing the incidence of inherited disease in dogs.) 

Male

Female

Yes

No

Less than 1 year

1-5 Years

6-10 Years

Greater than 10 Years

1

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require you to SAVE form to computer before fillable features are available.  After completed, you must SAVE.